Background: Early detection of hearing loss and subsequent intervention leads to better speech, language and educational outcomes giving way to improved social economic prospects in adult life. This can be achieved through establishing newborn and infant hearing screening programs. Objective: To determine the prevalence of hearing loss in newborns and infants in Nairobi, Kenya. Methods: A cross-sectional pilot study was conducted at the National hospital and at a sub county hospital immunization clinic. A total of 9,963 babies aged 0-3 years, were enrolled in the hearing screening program through convenient sampling over a period of nine months. A case history was administered followed by Distortion Product Oto-acoustic emissions (DPOAEs) and automated auditory brainstem response (AABR) hearing screening. Results: The screening coverage rate was 98.6% (9963/10,104). The referral rate for the initial screen was 3.6% (356/ 9,963), the return rate for follow-up rescreening was 72% (258 babies out of 356) with a lost to follow-up rate of 28% (98/356). The referral rate of the second screen was 10% (26/258). All the 26 babies referred from the second screen returned for diagnostic hearing evaluation and were confirmed with hearing loss, yielding a prevalence of 3/1000. Conclusions: Establishing universal newborn and infant hearing screening programs is essential for early detection and intervention for hearing loss. Data management and efficient follow-up systems are an integral part of achieving diagnostic confirmation of hearing loss and early intervention.

Although the World Health Organization defines health holistically (WHO 2016), and although a positive relationship exists between spirituality and health, maternity care globally focuses on physical and psychological care while excluding spiritual care. In Kenya, spiritual care in hospital settings has received little attention. Yet, cross-culturally, childbearing and motherhood are perceived to be highly spiritual events, but which may be traumatic especially if obstetric complications, postpartum depression, and death occur. Spiritual care is positively associated with patients’ ability to cope with negative experiences but also with a healthy birth process with optimal outcomes. Towards improving obstetric care by integrating professional clinical pastoral care in hospital settings in Kenya, we carried out a baseline study to explore the birthing physical, psychological and spiritual experiences of mothers of neonates admitted at the Neonatal Intensive Care Unit of the Riley Mother and Baby Hospital (RMBH) in Eldoret, Kenya. This article presents the results of the study.

Spiritual needs of care seekers, families and caregivers are ignored in maternity care in health facilities in Kenya. The quality of care remains poor with unacceptable maternal and neonatal mortalities. The Clinical Pastoral Education (CPE) Project at the College of Health Sciences of Moi University Eldoret, Kenya, aimed to integrate spiritual care into maternity care at The Riley Mother and Baby Hospital of The Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya, in order to provide holistic healthcare. In phase I, spiritual needs of mothers of neonates admitted to the Newborn Unit at the MTRH in Eldoret, Kenya, were assessed using a research protocol with modified North America validated tools (see Appendix) and unstructured interview guides. For phase II, hospital chaplains, trained using a Moi University post-graduate diploma curriculum for clinical pastoral education and care, were engaged as spiritual caregivers at the Hospital. In phase III, the same tools were used to re-assess spiritual needs after introducing spiritual care. This article presents challenges and progress made, lessons learnt from the CPE Project and knowledge gaps identified from the study. Baseline data showed lack of trained hospital chaplains and inadequate spiritual care at the Teaching and Referral hospital despite great need by patients, caregivers and families. Lack of precise definitions, theoretical and conceptual frameworks for spirituality in literature emerged as a challenge. The Kenya Chaplaincy Training Centre was initiated at the hospital to train hospital chaplains and healthcare providers who could provide spiritual care. A psychobiosocial conceptual framework, utility tools and a new theory for self-empowerment were proposed to address knowledge gaps in current literature.

The study evaluated the effectiveness of a neonatal nurse-training program in improving knowledge, patient care practices and processes of nurses in a neonatal intensive care unit in a resource-limited setting. The study was a pre-post intervention design assessing a nurse-training program in Kenya. We found a significant improvement in the primary outcome of nursing competency assessed on measures of knowledge and patient care practices post-intervention (p<0.0001). There was a decrease in the median length of stay post-intervention (p=0.03). After controlling for birth weight, mortality rate was significantly reduced post-intervention, OR 0.63 (95% CI: 0.42–0.99). In conclusion, a nurse training program, using a modified S.T.A.B.L.E. Program, among nurses in a resource-limited setting can significantly improve nurse competency and the quality of patient care as measured by improvement in knowledge, processes and crucial patient outcomes such as mortality.

We sought to determine if inhaled nitric oxide (iNO) administered to preterm infants with premature rupture of membranes (PPROM), oligohydramnios, and pulmonary hypoplasia improved oxygenation, survival, or other clinical outcomes. Data were analyzed from infants with suspected pulmonary hypoplasia, oligohydramnios, and PPROM enrolled in the National Institute of Child Health and Development Neonatal Research Network Preemie Inhaled Nitric Oxide (PiNO) trial, where patients were randomized to receive placebo (oxygen) or iNO at 5 to 10 ppm. Outcome variables assessed were PaO (2) response, mortality, bronchopulmonary dysplasia (BPD), and severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL). Twelve of 449 infants in the PiNO trial met criteria. Six infants received iNO and six received placebo. The iNO group had a mean increase in PaO (2) of 39 +/- 50 mm Hg versus a mean decrease of 11 +/- 15 mm Hg in the control group. Mortality was 33% versus 67%, BPD (2/5) 40% versus (2/2) 100%, and severe IVH or PVL (1/5) 20% versus (1/2) 50% in the iNO and control groups, respectively. None of these changes were statistically significant. Review of a limited number of cases from a large multicenter trial suggests that iNO use in the setting of PPROM, oligohydramnios, and suspected pulmonary hypoplasia improves oxygenation and may decrease the rate of BPD and death without increasing severe IVH or PVL. However, the small sample size precludes definitive conclusions. Further studies are required to determine if iNO is of benefit in this specific patient population.

OBJECTIVES. Our goal was to analyze the association between human milk intake and severe retinopathy of prematurity in extremely low birth weight infants. PATIENTS AND METHODS. This study is a secondary analysis of data collected for a trial of glutamine supplementation in extremely low birth weight infants (birth weight <1000 g). Among the 1433 participants in that trial, data are available regarding human milk intake and the occurrence of severe retinopathy of prematurity (defined in this study as retinopathy of prematurity treated surgically) for 1057 infants. The volume of human milk intake was expressed as the mean volume (milliliters per kilogram per day) and the mean proportional volume (proportion of total nutritional intake) from birth to discharge or transfer. Using logistic regression, we estimated odds ratios and 95% confidence intervals for any human milk intake and, among infants who received human milk, for each 10 mL/kg per day and each 10% increase in volume. RESULTS. Of the 1057 infants included in this cohort, 788 infants (75%) received at least some human milk. Among these milk-fed infants, the median volume of human milk intake was 30 mL/kg per day (interquartile range: 6–83 mL/kg per day), and the median proportional volume of human milk intake was 0.18 (interquartile range: 0.03–0.66). One hundred sixty-three infants (15%) developed severe retinopathy of prematurity. CONCLUSIONS. In extremely low birth weight infants, human milk intake was not associated with a decreased risk of severe retinopathy of prematurity.

Objectives We hypothesized that inhaled nitric oxide (iNO) would not decrease death or neurodevelopmental impairment (NDI) in infants enrolled in the National Institute of Child Health and Human Development Preemie iNO Trial (PiNO) trial, nor improve neurodevelopmental outcomes in the follow-up group.Study design Infants < 34 weeks of age, weighing < 1500 g, with severe respiratory failure were enrolled in the multicenter, randomized, controlled trial. NDI at 18 to 22 months corrected age was defined as:. moderate to severe cerebral palsy (CP; Mental Developmental Index or Psychomotor score Developmental Index < 70), blindness, or deafness.Results Of 420 patients enrolled, 109 who received iNO (52%) and 98 who received placebo (47%) died. The follow-up rate in survivors ,vas 90%. iNO did not reduce death or NDI (78% versus 73%; relative risk [RR], 1.07; 95% CI, 0.95-1.19), or NDI or Mental Developmental Index <70 in the follow-up group. Moderate-severe CP was slightly higher with iNO (RR, 2.41; 95% CI, 1.01-5.75), as was death or CP in infants weighing < 1000 g (RR, 1.22; 95% Cl, 1.05-1.43).Conclusions In this extremely ill cohort, iNO did Hot reduce death or NDI or improve neurodevelopmental outcomes. Routine iNO use in premature infants should be limited to research settings until further data are available.

OBJECTIVE:To document the mortality and morbidity of infants weighing 501-1500 g at birth according to gestational age, birthweight, and sex.STUDY DESIGN:Prospective collection of perinatal events and neonatal course to 120 days of life, discharge, or death from January 1990 through December 2002 for infants born at 16 participating centers of the National Institute of Child Health & Human Development Neonatal Research Network.RESULTS:Compared with 1995-1996, for 1997-2002 the survival of infants with birthweight of 501-1500 g increased by 1 percentage point (from 84% to 85%). Survival without major neonatal morbidity remained static, at 70%; this includes bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Survival increased for multiple births (26%, up from 22%), antenatal corticosteroid use (79%, up from 71%), and maternal antibiotics (70%, up from 62%) (P < .05). From 1997 to 2002, birthweight-specific survival was 55% for infants weighing 501-750 g, 88% for 751-1000 g, 94% for 1001-1250 g, and 96% for 1251-1500 g. More females survived. The incidence of NEC (7%), severe IVH (12%), and late-onset septicemia (22%) remained essentially unchanged, but BPD decreased slightly, from 23% to 22%. The use of postnatal corticosteroids declined from 20% in 1997-2000 to 12% in 2001-2002. Growth failure (weight <10th percentile) at 36 weeks' postmenstrual age decreased from 97% in 1995-1996 to 91% in 1997-2002.CONCLUSION:There have been no significant increases in survival without neonatal and long-term morbidity among VLBW infants between 1997 and 2002. We speculate that to improve survival without morbidity requires determining, disseminating, and applying best practices using therapies currently available, and also identifying new strategies and interventions.

OBJECTIVE:To determine whether earlier treatment of high-risk, prethreshold retinopathy of prematurity (ROP) improves retinal structural outcome at 2 years of age.METHODS:Infants with bilateral high-risk prethreshold ROP had one eye randomly assigned to treatment with peripheral retinal ablation. The fellow eye was managed conventionally, and either treated at threshold ROP or observed if threshold was never reached. In patients with asymmetrical disease, the high-risk, prethreshold eye was randomised to earlier treatment or to conventional management. At 2 years of age, children were examined comprehensively by certified ophthalmologists to determine structural outcomes for their eyes. For the purposes of this study, an unfavourable structural outcome was defined as (1) a posterior retinal fold involving the macula, (2) a retinal detachment involving the macula or (3) retrolental tissue or "mass" obscuring the view of the posterior pole. Results of the 2-year examination were compared with those from the 9 months examination.RESULTS:Data were available on 339 of 374 (90.6%) surviving children. Unfavourable structural outcomes were reduced from 15.4% in conventionally managed eyes to 9.1% in earlier-treated eyes (p = 0.002) at 2 years of age. Ophthalmic side effects (excluding retinal structure) from the ROP or its treatment were similar in the earlier-treated eyes and the conventionally managed eyes.CONCLUSION:The benefit of earlier treatment of high-risk prethreshold ROP on retinal structure endures to 2 years of age, and is not counterbalanced by any known side effect caused by earlier intervention. Earlier treatment improves the chance for long-term favourable retinal structural outcome in eyes with high-risk prethreshold ROP. Long-term follow-up is planned to determine structural and functional outcomes at 6 years of age.

OBJECTIVE: To evaluate the costs and performance characteristics associated with the start-up phase of Universal Newborn Hearing Screening Programs, one utilizing automated auditory brainstem response (AABR) and the other using transient evoked otoacoustic emissions (TEOAE). STUDY DESIGN: Economic and performance data were collected at the initiation of both screening programs. Data were collected until 1500 newborn infants were screened or until a referral rate for further audiologic evaluation at hospital discharge of less than or equal to 5% was achieved. Data collected included screening pass/fail rates, referral rates and personnel, equipment, and supply utilization. Actual costs of personnel, equipment, and supplies were used. Statistical comparisons of proportions using z-statistic with the one-tailed test and an α of 0.01 were made. RESULTS: Screening in the AABR program was performed by neonatal nurses, whereas screening in the TEOAE program was performed by master's level audiologists. The average age at initial screen was 29 hours for TEOAE, and 9.5 hours for AABR. Eighty-four percent of infants was screened within 24 hours in the AABR program, in contrast to 35% in the TEOAE program. Throughout the duration of the study, the referral rate at hospital discharge remained approximately 15% for the TEOAE program. The AABR referral rate began at 8% and was less than 4% at the completion of the study. Pre-discharge total costs for initiating and establishing the programs were US$49,316 for TEOAE and US$47,553 for AABR. Cost per infant screened was US$32.23 and US$33.68, respectively. When post-discharge screening and diagnostic evaluation costs were included, the total cost per infant screened was US$58.07 for TEOAE and US$45.85 for AABR. CONCLUSION: AABR appears to be the preferred method for universal newborn hearing screening. AABR was associated with the lowest costs, achieved the lowest referral rates at hospital discharge, and had the quickest learning curve to achieve those rates.

1. Paula A. Farrell, MD* 2. Gary M. Weiner, MD* 3. James A. Lemons, MD† 1. *Department of Pediatrics, Section of Neonatal-Perinatal Medicine, James Whitcomb Riley Hospital for Children 2. †Hugh McK. Landon Professor of Pediatrics; Director, Section of Neonatal-Perinatal Medicine, Indiana University, Indianapolis, IN. After completing this article, readers should be able to: 1. Describe the effects of the “Back to Sleep” campaigns on the incidence of sudden infant death syndrome (SIDS). 2. Delineate modifiable risk factors of SIDS. 3. Explain the relationship of apnea and SIDS. 4. Delineate recommendations for the prevention of SIDS. Sudden infant death syndrome (SIDS) has been the focus of extensive research over the past several decades. This review examines the epidemiologic aspects of this syndrome, potential prevention strategies, and the use of home monitoring. Also referred to as crib or cot death, SIDS has been defined by the National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring as “the sudden death of an infant or young child, which is unexplained by history and in which a thorough postmortem evaluation fails to demonstrate an adequate cause of death.” A thorough postmortem evaluation includes a complete autopsy, review of the death scene, and review of the clinical history. The consensus statement defined an apparent life-threatening event (ALTE) as “an episode that is frightening to the observer and is characterized by some combination of apnea, color change, change in muscle tone, choking, or gagging.” It is noted in this statement that terminology used previously, such as “aborted crib death” or “near-miss SIDS,” should be abandoned because it implies a possibly misleadingly close association between this type of spell and SIDS. Apnea of infancy is defined as an unexplained episode of cessation of breathing for 20 seconds or longer or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, or marked hypotonia. This generally is applied to infants who are older than 37 weeks’ gestation. This diagnosis usually is reserved for infants who have ALTE for which a specific cause has not been delineated that is believed to have been related to …

OBJECTIVE Late-onset sepsis (occurring after 3 days of age) is an important problem in very low birth weight (VLBW) infants. To determine the current incidence of late-onset sepsis, risk factors for disease, and the impact of late-onset sepsis on subsequent hospital course, we evaluated a cohort of 6956 VLBW (401-1500 g) neonates admitted to the clinical centers of the National Institute of Child Health and Human Development Neonatal Research Network over a 2-year period (1998-2000). METHODS The National Institute of Child Health and Human Development Neonatal Research Network maintains a prospective registry of all VLBW neonates admitted to participating centers within 14 days of birth. Expanded infection surveillance was added in 1998. RESULTS Of 6215 infants who survived beyond 3 days, 1313 (21%) had 1 or more episodes of blood culture-proven late-onset sepsis. The vast majority of infections (70%) were caused by Gram-positive organisms, with coagulase-negative staphylococci accounting for 48% of infections. Rate of infection was inversely related to birth weight and gestational age. Complications of prematurity associated with an increased rate of late-onset sepsis included patent ductus arteriosus, prolonged ventilation, prolonged intravascular access, bronchopulmonary dysplasia, and necrotizing enterocolitis. Infants who developed late-onset sepsis had a significantly prolonged hospital stay (mean length of stay: 79 vs 60 days). They were significantly more likely to die than those who were uninfected (18% vs 7%), especially if they were infected with Gram-negative organisms (36%) or fungi (32%). CONCLUSIONS Late-onset sepsis remains an important risk factor for death among VLBW preterm infants and for prolonged hospital stay among VLBW survivors. Strategies to reduce late-onset sepsis and its medical, social, and economic toll need to be addressed urgently.

BACKGROUND:It is uncertain whether the rates and causes of early-onset sepsis (that occurring within 72 hours after birth) among very-low-birth-weight infants have changed in recent years, since antibiotics have begun to be used more widely during labor and delivery. METHODS:We studied 5447 very-low-birth-weight infants (those weighing between 401 and 1500 g) born at centers of the Neonatal Research Network of the National Institute of Child Health and Human Development between 1998 and 2000 who had at least one blood culture in the first three days of life and compared them with 7606 very-low-birth-weight infants born at centers in the network between 1991 and 1993. RESULTS:Early-onset sepsis (as confirmed by positive blood cultures) was present in 84 infants in the more recent birth cohort (1.5 percent). As compared with the earlier birth cohort, there was a marked reduction in group B streptococcal sepsis (from 5.9 to 1.7 per 1000 live births of infants weighing 401 to 1500 g, P<0.001) and an increase in Escherichia coli sepsis (from 3.2 to 6.8 per 1000 live births, P=0.004); the overall rate of early-onset sepsis was not significantly changed. Most E. coli isolates from the recent birth cohort (85 percent) were resistant to ampicillin, and mothers of infants with ampicillin-resistant E. coli infections were more likely to have received intrapartum ampicillin than were those with ampicillin-sensitive strains (26 of 28 with sensitivity data vs. 1 of 5, P=0.01). Infants with early-onset sepsis were more likely to die than uninfected infants (37 percent vs. 13 percent, P<0.001), especially if they were infected with gram-negative organisms. CONCLUSIONS:Early-onset sepsis remains an uncommon but potentially lethal problem among very-low-birth-weight infants. The change in pathogens over time from predominantly gram-positive to predominantly gram-negative requires confirmation by ongoing surveillance.

Objective: To investigate the costs and referral rates of 3 universal newborn hearing screening programs: transient evoked otoacoustic emissions (TEOAE), automated auditory brainstem response (AABR), and a combination, two-step protocol in which TEOAE and AABR are used.Study design: Clinical outcomes (referral rates) from 12,081 newborns at 5 sites were obtained by retrospective analysis. Prospective activity-based costing techniques (n = 1056) in conjunction with cost assumptions were used to analyze the costs based on an assumed annual birth rate of 1500 births.Results: Referral rates differed significantly among the 3 screening protocols (AABR, 3.21%; two-step, 4.67%; TEOAE, 6.49%; P <.01), with AABR achieving the best referral rate at discharge. Although AABR had the lowest referral rate at discharge and the highest pre-discharge costs, the total pre- and post-discharge costs per infant screened (AABR, $32.81; two-step, $33.05; TEOAE, $28.69) and costs per identified child (AABR, $16,405; two-step, $16,527; TEOAE, $14,347) were similar among programs.Conclusion: Although AABR incurs higher costs during pre-discharge screening, it has lower referral rates than either the TEOAE or two-step program. As a result, the total costs of newborn hearing screening and diagnosis are similar among the 3 methods studied.

This statement is intended for health care professionals caring for neonates (preterm to 1 month of age). The objectives of this statement are to:1. Increase awareness that neonates experience pain;2. Provide a physiological basis for neonatal pain and stress assessment and management by health care professionals;3. Make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and4. Recommend effective and safe interventions that relieve pain and stress.